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Rapid Responses: Rapid Responses published:
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Public health policy must be based on sound evidence, not opinion
- Michael DE Goodyear (6 April 2007)
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Should prostitution be legalised and regulated?
- C J Spencer Jones (16 April 2007)
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Sex workers, STIs & prostitution policy
- Hilary R Kinnell (18 April 2007)
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Michael DE Goodyear, Assistant professor Department of Medicine, Dalhousie University, Halifax, Nova Scotia CANADA B3H 2Y9
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As emphasized by Day and Ward, it is essential that public policy be firmly grounded on high quality evidence. Unfortunately the discourse in public health, and in particular that concerning services to individuals involved in commercial sex, are more likely to be informed by opinion than by evidence. (2) In addition repeated exposure to messages reinforces and polarizes previously held prejudices. (3-5) A case in point is a widely circulated report of a British Medical Association (BMA) Public Health Committee conference on March 29. (6) This report stated that 70% of all sexually transmitted infections (STIs) in Birmingham occur among prostitutes and their clients. This statement cannot be supported either in Birmingham, West Midlands or elsewhere in the UK, nor is specific targeting of the commercial sex community as a high risk group a priority in the delivery of sexual health services in the UK, (7) rather the concern is access to services and screening for Chlamydia in the 15-24 age group. Sex workers have a relatively low prevalence of STIs and are most at risk from activities unconnected with their work. This achievement is very dependent on the close partnerships between the commercial sex community and outreach projects, a partnership threatened by these proposals. The SAFE project in Birmingham, and its integration into the Sexual Health Directorate there, has been a model in this respect. It is not only untrue, but also unfair to once again blame sex workers for the transmission of STIs and HIV/AIDS, and shows a poor understanding of the epidemiology and transmission of these diseases, apart from an obvious double sexual standard. (8) Discussions around regulatory frameworks in commercial sex require care in relation to terminology. This report appears to be advocating the legalization and regulation of sex work in order to submit “prostitutes …to regular testing”. This approach is not only unjustified, and an affront to human dignity and rights, but an inappropriate diversion of scarce NHS resources. Furthermore it would be ineffective, and dangerous. (9,10) Coercion of sex workers merely drives them further underground and alienates them from the services they need, leading to a breakdown in sexual health practices, and an increase in STI transmission. (11) This appears to be a re-enactment of the disastrous mid nineteenth century legislation that enforced medical examinations of ‘suspected common prostitutes’. (12) An illustration is provided by recent reports of syphilis in London street workers. (13) A street worker reported symptoms to an outreach team, and very rapidly other women started to develop similar problems, the team arranged care and invited other workers to come in for screening. These women were infected by clients, rather than being a reservoir themselves, and no amount of coercive examination would have achieved the degree of control of this outbreak that resulted from the trust established between the women, the outreach team, and the Genito-Urinary Medicine team. It would be interesting to know where the costing of £20-25 million per year for this proposed policy was derived from, in any case it would be better injected into the provision of population based sexual health services and of specialized services for the sex work community. However the appropriate comparator would be the current cost of inappropriate and ineffective policing, rather than the cost of sexual health services whose scope is quite wide. Sexual health is a key national priority and it is a pity that more publicity was not given to the real issues discussed at this conference, the lack of resources, which this report distracts attention from. It is decriminalization of sex work that the health and social services sector is demanding based on sound evidence, not legalization. (14) This would enable improved access and provision of services to these needy and marginalized people. Statements that UK rates of STIs and HIV/AIDS are largely due to immigration policies (and by implication that most migrants are sex workers), and in particularly singling out specific nationalities, are unfair and dangerous, and likely to lead to increased racial tension, violence and reinforcement of prejudices. Nor is public health the place for sensationalist statements such as describing the West Midlands HIV prevalence as ‘astronomical’. Moral panic has never been a sound basis for building health policy. As Day and Ward stress, the major health problems amongst sex workers are related to stigmatization (15) which this report contributes further to. Inaccurate and inflammatory statements such as these reported comments are likely to lead to increased levels of violence against them, as seen recently in Ipswich, and will even place outreach workers at risk. It is even more unfortunate that such statements are being attributed to the BMA, giving them an undeserved authority, and hence credibility. They do not reflect BMA policy, (16) and the BMA needs to clarify this with some urgency, look to its accountability, and return to evidence based practice. References 1. Day S, Ward H. British policy makes sex workers vulnerable. BMJ 2007 334: 187 2. Hubbard P. Sexuality, immorality and the city: red-light districts and the marginalization of female street prostitutes. Gender Place Culture 1998 5(1): 5-72 3. Tesser A, Conlee M. Some effects of time and thought on attitude polarization. J Personality Soc Psychol 1975 31(2): 262-270 4. Caciopppo J, Petty R. Effects of message repetition and position on cognitive response, recall, and persuasion. J Personality Soc Psychol 1979 37(1): 97-109 5. Lodge M, Taber C. The automaticity of affect for political leaders, groups, and issues: an experimental test of the hot cognition hypothesis. Political Psychology 2005 26(3): 455-482. 6. LifeStyleExtra. ‘Legalise prostitution to save NHS cash’ March 29 2007. http://www.lse.co.uk/ShowStory.asp?story=MH2935662C&news_headline=legalise_prostitution_to_save_nhs_cash (accessed April 5 2007) 7. Cassell JA, Mercer CH, Imrie J et al. Who uses condoms with whom? Evidence from national probability sample surveys. Sex Transm Infect 2006; 82: 467-473. 8. Ward H, Day S, Weber J. Risky business: health and safety in the sex industry over a 9 year period. Sex. Transm. Infect. 1999; 75:340-343 9. United Kingdom Network of Sex Work Projects. Response to “Paying the Price” November 26 2004 http://www.uknswp.org/UKNSWP_Paying_the_Price_response.pdf 10. Ward H, Aral SO. Globalisation, the sex industry, and health. Sex Transm Infect 2006 82: 345-347 11. Jeal N, Salisbury C. Self-reported experiences of health services among female street-based prostitutes: a cross-sectional survey. Br J Gen Pract. 2004 Jul;54(504):515-9. 12. Roberts M.J.D. Feminism and the State in Later Victorian England. The Historical Journal 1995 Mar. 38(1): 85-110. 13. Lomax N, Wheeler H, Anaraki S, Anderson H, Goh B. Management of a syphilis outbreak in street sex workers in east London. Sex Transm Infect. 2006 Dec;82(6):437-8. 14. Goodyear M, Cusick L. Protection of sex workers: decriminalization could restore public health priorities and human rights. BMJ 2007 224: 52-3. 15. Ward H, Day S. What happens to women who sell sex? Report of a unique occupational cohort. Sex Transm Infect. 2006 Oct;82(5):413-7 16. BMA. Sexually transmitted infections: An update from the Board of Science January 2007 http://www.bma.org/ap.nsf/content/stiupd07 Acknowledgments: Nicholas Pascoe, Lisa Fitzgerald, Gillian Abel, Cheryl Brunton, Department of Public Health and General Practice, University of Otago, Christchurch, New Zealand; UK Network of Sex Work Projects Competing interests: None declared |
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C J Spencer Jones, Chair, CPHMCH BMA House, Tavistock Square
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The BMA's annual Public Health conference is an opportunity for doctors to air and public health issues and debate them. To challenge each other and establish what is known and what is not known. The specialty of public health takes evidence based medicine at least as seriously as other specialties, but from time to time it is important to free oneself from its fetters. On 29 March a motion was put forward from the West Midlands region (that I drew up): "That this conference believes that the key to prevention of sexually transmitted disease is two-fold: (i) school-based education that ensures that all children understand the risks associated with unprotected sexual intercourse before they become sexually active, and (ii) the legalisation and regulation of prostitution." The first part of the motion was accepted by the conference. The second part was taken "as reference": a polite way of saying, go back and work on this more. The BMA press office issued a press release ahead of the conference to excite press interest. I believe it included reference to part (ii) of the motion, which I would not have endorsed. There were journalists from national newspapers present at the conference, none of whom published copy on this. One journalist rang up the BMA press office, who asked me to respond. It was a journalist from the Daily Sport, who wanted to know the background to the motion. I told the journalist that 70% of frequent fliers at STI clinics work in the pay for sex sector. I confirmed that I had put forward the motion to be debated and believed that legalisation and regulation might reduce STIs by 50% over time, largely because it would help to bring the fringe sex- workers (who are the group who have unprotected sex) into the main pay for sex economy. I suggested that the journalist talk to experts if he wanted more facts, and cited the SAFE project in Birmingham. He asked me how much I thought is spent on specialist sexual health clinics in the UK and I suggested a figure of about £660m but stressed that this was a rough estimate. The Daily Sport was not entirely accurate in its use of this conversation, nor was it entirely inaccurate. There was a piece in the BMJ's News section this week that repeated the figures put out by the Daily Sport, repeating an error that any experts have rightful cause to be concerned about (70% of STIs do not come from sex workers - that would be nonsense, though surely that sector has had a major role in the total STIs in circulation?). I have to say that my reason for submitting the motion seems to have served its primary purpose: to open up some debate. I urge colleages to consider that it is as important to think about the "big picture" of what is going on in our society as well as what is going on in any specialty. Certainly that is what we feel we have to do in public health. Question then. Should prostitution be legalised and regulated? It is an honest question. Competing interests: None declared |
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Hilary R Kinnell, author Telford TF7 5AR
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Dr Spencer-Jones's clarification that 70% of frequent attenders at STI clinics in Birmingham are involved in the sex industry (not 70% of all STIs attributable to commercial sex) is most welcome, since it suggests that Birmingham sex workers are careful about their sexual health, and go for regular check-ups, without any state compulsion or registration. However, Dr Spencer-Jones does not mention that the efforts of the SAFE outreach project for sex workers in Birmingham have been seriously impeded for several years, by being banned from distributing condoms in Birmingham's main area of street soliciting, because of objections from local residents. The "zero tolerance" approach to street soliciting is practiced (despite continued failure) in many cities, but Birmingham is the only place where both the local authority, and the health authorities, have undermined basic STI and HIV prevention in this way. Hilary Kinnell SAFE Project Manager, 1987-1996 Competing interests: None declared |
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